Announcements: Neuromuscular section updated with more questions.

HISTORY: New onset seizure or known epileptic?

If known epileptic, goal is to determine AED regimen and compliance, seizure type/frequency and last seizure, epilepsy physician, any recent triggers (see below).  Check AED levels and if low or they are non-compliant, re-load; if not, consider increasing AED dose. Ask about prior AEDs tried.

If new onset seizures, obtain comprehensive first seizure history:

  • RISK FACTORS: history of febrile seizures, family history of seizures, prenatal and perinatal complications, developmental delay, history of head trauma, history of CNS infection, history of CNS mass
  • TRIGGERS LOWERING SEIZURE THRESHOLD: medications, antiepileptic noncompliance, infection, metabolic abnormalities, toxic ingestion, menses, stress, sleep deprivation, EtOH / benzo withdrawal, bright lights or loud noise
  • CHARACTERISTICS: aura (visual, auditory, olfactory, epigastric rising sensation,  psychic (déjà vu, derrealization, depersonalization, fear, anxiety), type of seizure (especially how its starts), eyes open or closed, lateral eye or head deviation, length of seizure, associated tongue bite or other injury, incontinence, presence of post-ictal confusion, post-ictal weakness.
  • SUBTLE SEIZURE SIGNS: history of staring, automatisms, waking up incontinent or injured (tongue bite). myoclonic jerks.

 EXAM: full neurologic exam paying close attention to mental state, post-ictal paralysis or other focal deficits, subtle signs of ongoing seizures such as abnormal movements, head or eye deviation, eyelid twitching, pupillary abnormalities or hippus; also check for tongue bite / other injury, and check meningeal signs

 ED WORKUP: AED levels, non-contrast head CT, basic labs including electrolytes and CBC, infectious workup (UA, CXR), tox screen, LP if concern for meningitis


  • AED: load and then standing dose if warranted
  • EEG:  for new onset seizure if EEG done within 24-48 hrs has highest yield. Order sleep deprived if possible.
  • MRI with and without contrast, seizure protocol if warranted
  • seizure precautions
  • ativan IV PRN seizure activity
  • evaluate medication list to see if anything lowers seizure threshold
  • code status
  • no driving for ≥ 3 months per CT state law
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